Iggy Chapter 29 - Respiratory Assessment

7. 7. People involved in which occupations or activities are encouraged to wear masks and to have adequate ventilations? Select all that apply. A. Bakers B. Coal miners C. Electricians D. Furniture refinishers E. Plumbers F. Potters

A, B, D, F

A client with asthma reports shortness of breath. What is the nurse assessing when auscultating this client's chest? A. Adventitious breath sounds B. Fremitus C. Oxygenation status D. Respiratory excursion

A. Adventitious breath sounds Correct: Adventitious sounds are additional breath sounds superimposed on normal sounds. They indicate pathologic changes in the lung.

Which of the components of a client's family history are of particular importance to the home health nurse who is assessing a new client with asthma? A. Brother is allergic to peanuts. B. Father is obese. C. Mother is diabetic. D. Sister is pregnant.

A. Brother is allergic to peanuts. Correct: Clients with asthma often have a family history of allergies. It will be important to assess whether this client has any allergies that may serve as triggers for an asthma attack.

Four clients are sent back to the emergency department from triage at the same time. Which client requires the nurse's immediate attention? A. Client with acute allergic reaction B. Client with dyspnea on exertion C. Client with lung cancer with cough D. Client with sinus infection with fever

A. Client with acute allergic reaction Correct: An acute allergic reaction can lead to immediate respiratory distress. This is an emergent situation that requires the immediate attention of the nurse.

The RN has received report about all of these clients. Which client needs the most immediate assessment? A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry B. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes C. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago D. Client with pleural effusion who has decreased breath sounds at the right base

A. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry Correct: An oxygen saturation level less than 91% indicates hypoxemia and requires immediate assessment and intervention to improve blood and tissue oxygenation.

The nurse auscultates popping, discontinuous sounds over the client's anterior chest. How does the nurse classify these sounds? A. Crackles B. Rhonchi C. Pleural friction rub D. Wheeze

A. Crackles Correct: Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways. The airways have been deflated due to the presence of fluids in the lungs, and crackles should be considered to be a sign of fluid overload.

A client is admitted to the medical floor with a new diagnosis of lung cancer. How can the nurse assist the client initially with the anxiety associated with the new diagnosis? A. Encourage client to ask questions and verbalize concerns. B. Leave client alone to deal with his own feelings. C. Medicate client with diazepam (Valium) for anxiety every 8 hours. D. Provide journals about cancer treatment.

A. Encourage client to ask questions and verbalize concerns. Correct: Anxiety causes increased oxygen consumption. Oxygen availability is limited in lung cancer. The availability of the nurse to answer questions and listen to the client's concerns will decrease anxiety.

Where does gas exchange occur? A. Acinus B. Alveolus C. Bronchus D. Carina

B. Alveolus Correct: The alveolus is the structural unit of the lung where gas exchange occurs.

Which of these assessment findings will be of greatest concern when the nurse is assessing a client with emphysema? A. Barrel-shaped chest B. Bronchial breath sounds heard at the bases C. Hyperresonance to percussion of the chest D. Ribs lying horizontal

B. Bronchial breath sounds heard at the bases Correct: Bronchial breath sounds are not normally heard in the periphery and may indicate increased lung density, as in a tumor or an infective process such as pneumonia.

The nurse is performing a client assessment for the client's potential employer. The client reports dyspnea when climbing stairs but is not dyspneic at rest. Which dyspnea classification does the nurse assign to this client in the report to the employer? A. Class I, can perform perform manual labor B. Class II, can perform desk job C. Class III, minimally employable D. Class IV, must remain at home

B. Class II, can perform desk job Correct: This client is dyspneic when climbing stairs or walking on an incline but not on level walking. Therefore, this client is employable only for a sedentary job or under special circumstances.

In assessing the client's respiratory status, blood gas test results reveal pH of 7.50, PaO2 of 99, PaCO2 of 29, and HCO of 22. What action does the nurse need to take first? A. Call the physician. B. Encourage the client to slow his breathing rate. C. Nothing. These results are within the normal range. D. Provide oxygen support.

B. Encourage the client to slow his breathing rate. Correct: The arterial blood gases (ABGs) indicate respiratory alkalosis, which is commonly caused by hyperventilation. Encouraging the client to slow down his breathing rate may help him return to normal breathing and may correct this abnormality.

The client returns to the medical unit after a therapeutic bronchoscopy. Which intervention does the nurse apply first? A. Assess the puncture site for drainage. B. Implement NPO (nothing by mouth) status. C. Monitor for signs of anaphylaxis. D. Perform aggressive chest physiotherapy.

B. Implement NPO (nothing by mouth) status. Correct: Until the client has a gag reflex and is fully alert, he should be maintained on NPO status to prevent aspiration.

Why are the turbinates important? A. They decrease the weight of the skull on the neck. B. They increase the surface area of the nose for heating and filtering. C. They move inspired particles from nose to throat for removal. D. They separate two nasal passages down the middle.

B. They increase the surface area of the nose for heating and filtering. Correct: The turbinates increase the surface area of the nose, so that more heating, filtering, and humidifying of inspired air can occur before air passes into the nasopharynx.

You are a charge nurse on a surgical floor. The LPN/LVN informs you that a new client who had an earlier bronchoscopy has the following vital signs: heart rate 132, respiratory rate 26, and blood pressure 98/50. The client is anxious and his skin is cyanotic. What will be your first action? A. Call the Rapid Response Team. B. Give methylene blue 1% 1 to 2 mg/kg by IV injection C. Administer oxygen. D. Notify the physician immediately.

C. Administer oxygen. Correct: Administering oxygen and reassessing vital signs to observe for improvement is the first action. Administration of oxygen by itself may help relieve the client's anxiety.

Four clients arrive in the emergency department simultaneously with chest pain. The client with which type of chest pain requires immediate attention by the nurse? A. Client with pain on deep inspiration B. Client with pain on palpation C. Client with pain radiating to the shoulder D. Client with pain that is rubbing in nature

C. Client with pain radiating to the shoulder Correct: Chest pain radiating to the shoulder should be assumed to be cardiac in origin until proven otherwise; this requires the immediate attention of the nurse.

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What diagnostic test will the nurse teach the client about to help confirm the diagnosis? A. Bronchoscopy B. Chest x-ray C. Computed tomography (CT) scan D. Thoracoscopy

C. Computed tomography (CT) scan Correct: CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.

Which nursing intervention is the priority in preparing the client for pulmonary function testing (PFT)? A. Administer bronchodilator medication on call. B. Encourage clear fluid intake 12 hours before the procedure. C. Ensure no smoking 6 hours before the test. D. Provide supplemental oxygen as testing begins.

C. Ensure no smoking 6 hours before the test. Correct: If the client has been smoking, this may alter parts of the PFT (diffusing capacity [DlCO]), yielding inaccurate results.

A client is having surgery. He asks his nurse, "When they put that tube in my throat, where does it really go?" What is the name of the opening of the vocal cords? A. Arytenoid cartilage B. Epiglottis C. Glottis D. Palatine tonsils

C. Glottis Correct: The glottis is the opening of the vocal cords into which the endotracheal tube is passed during intubation for surgery.

A client comes to the emergency department with a productive cough. Which symptom does the nurse look for that will require immediate attention? A. Blood in the sputum B. Mucoid sputum C. Pink frothy sputum D. Yellow sputum

C. Pink frothy sputum Correct: Pink frothy sputum is common with pulmonary edema and requires immediate attention and intervention to prevent the client's condition from getting worse.

A client had a thoracentesis 1 day ago. He calls the home health agency and tells the nurse that he is very short of breath and anxious. What is the major concern of the nurse? A. Abscess B. Pneumonia C. Pneumothorax D. Pulmonary embolism

C. Pneumothorax Correct: A pneumothorax would be the complication of thoracentesis that causes the greatest concern, along with these symptoms.

The client has a fever of 40° C. In which direction, if any, will this shift the oxyhemoglobin dissociation curve? A. Down B. To the left C. To the right D. Will not shift

C. To the right A client with fever has a higher demand for oxygen, so the curve will shift to the right for easier dissociation.

The home health nurse is assigned to visit all of these clients when a change in agency staffing requires that one of the clients should be rescheduled for a visit on the following day. Which of these clients would be best to reschedule? A. Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93% B. Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test C. Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment D. Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

Client with emphysema who has been on home oxygen for a month and has SPO2 levels of 91% to 93% Correct: This client has an appropriate Spo2 for home oxygen use.

The nurse is working in an urgent clinic. Which of these four clients needs to be evaluated first by the nurse? A. Client who is short of breath after walking up two flights of stairs B. Client with soreness of the arm after receiving purified protein derivative (PPD) (Mantoux) skin test C. Client with sore throat and fever of 39° C oral D. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry

D. Client who is speaking in three-word sentences and has SaO2 of 90% by pulse oximetry Correct: A client should be able to speak in sentences of more than three words, and Sao2 of 90% indicates hypoxemia that requires intervention on the part of the nurse.

Which of these clients will the charge nurse on the medical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? A. Client with allergic rhinitis scheduled for skin testing B. Client with emphysema who needs teaching about pulmonary function testing C. Client with pancreatitis who needs a preoperative chest x-ray D. Client with pleural effusion who has had 1200 mL removed by thoracentesis

D. Client with pleural effusion who has had 1200 mL removed by thoracentesis Correct: A nurse working in the PACU would be familiar with assessing vital signs and respiratory status after procedures such as thoracentesis.

3. 3. A client has returned to the postanesthesia care unit (PACU) after a bronchoscopy. Which of these nursing tasks is best for the charge nurse to delegate to the experienced nursing assistant working in PACU? A. Assess breath sounds. B. Check gag reflex. C. Determine level of consciousness. D. Monitor blood pressure and pulse.

D. Monitor blood pressure and pulse. Correct: A nursing assistant working in the PACU would have experience in taking client vital signs after the client has had conscious sedation or anesthesia.

An RN and an LPN/LVN are working together to provide care for a client hospitalized with dyspnea who requires all of these nursing actions. Which of these actions is best accomplished by the RN? A. Administer the purified protein derivative (PPD) for tuberculosis testing. B. Assess vital signs and the puncture site after thoracentesis. C. Monitor oxygen saturation using pulse oximetry every 4 hours. D. Plan client and family teaching regarding upcoming pulmonary function testing.

D. Plan client and family teaching regarding upcoming pulmonary function testing. Correct: Developing the teaching plan is the most complex of the skills listed and requires RN education and licensure.

In the older adult client, which respiratory change does not require further assessment by the nurse? A. Increased anteroposterior (AP) diameter B. Increased respiratory rate C. Shortness of breath D. Sputum production

Increased anteroposterior (AP) diameter Correct: Increased AP diameter is normal with aging.